Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

SENSORY PERCEPTION:
the ability to respond to pressure-related discomfort

1. Completly Limited
Unresponsive (does not moan, flinch or grasp) to painful stimuli, due to diminished level of consciousness or sedation,OR
limited ability to feel pain over most of body

2. Very Limited
Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness,OR
has a sensor impairment that limits the ability to feel pain or discomfort over 1/2 of body.

3. Slightly Limited
Responds to verbal commands, but cannot always communicate discomfort or the need to be turned, OR
has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. No Impairment
Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

1. Very Poor
Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR
is NPO and/or maintained on clear liquids or IVs for more than 5 days

2. Probably Inadequate
Rarely eats a complete meal and generally eats only about 1/2 of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR
receives less than optimum amount of liquid diet or tube feeding.

3. Adequate
Eats over half of most meals. Eats a total of 4 servings of protein (meat or dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered OR
is on a tube feeding or TPN regimen, which meets most of nutritional needs.

4. Excellent
Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

1. Problem
Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction.

2. Potential Problems
Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem
Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.

Subtotal:

TOTAL: _____________

Note: Individuals with a score of 18 or less are considered to be at risk of developing pressure ulcers.